Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)

Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy (OPT) and/or Speech Pathology Services (OSP)- Initial and Extension Site Requests (CMS-381)

Documents and Forms

Document Name Document Type
Form CMS-381 Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381) Form and Instruction
CMS-381 REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAI Combined Form CMS-1856 and CMS-381 (Final).pdf Form and Instruction
CMS-381 REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAI Combined Form CMS-1856 and CMS-381 (Final).pdf Form and Instruction
Combined Form CMS-1856 and CMS-381 (Crosswalked).docx Tracked changes IC Document
Combined Form CMS-1856 and CMS-381 (Crosswalked).docx Tracked changes IC Document
Crosswalk for Reviewers.docx Crosswalk IC Document
Crosswalk for Reviewers.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 485.701-485.729

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-381	REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAID PROGRAM TO PROVIDE OUTPATIENT PHYSICAL THERAPY (OPT) AND/OR SPEECH PATHOLOGY SERVICES (OSP)- INITIAL AND EXTENSION SITE REQUESTS	Combined Form CMS-1856 and CMS-381 (Final).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 506	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	506	63	443
Annual IC Time Burden (Hours)	253	142	111
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Tracked changes	Combined Form CMS-1856 and CMS-381 (Crosswalked).docx	06/12/2024
Crosswalk	Crosswalk for Reviewers.docx	06/12/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.